Resource reuse has become an important aspect of wastewater management. At present, use of sludge in agriculture is one of the major reuse routes. Conventional municipal wastewater treatment does not involve any designated process for removal of heavy metals, and these distribute mainly between effluent and sludge. Enhanced removal of heavy metals during primary treatment may decrease the heavy metal concentrations in both effluent and sludge from secondary treatment and promote long-term reuse of secondary sludge. This review considers heavy metal occurrence and removal during primary settling, together with possible treatment technologies for heavy metal removal in primary settlers and their theoretical performance. The variation in total heavy metal concentrations and dissolved fraction in raw municipal wastewater points to a need for site-specific assessments of appropriate technologies for improved heavy metal removal. Studies examining the heavy metal speciation beyond dissolved/particulate are few. Missing or disparate information on process parameters such as hydraulic retention time, pH and composition of return flows makes it hard to generalize the findings from studies concerning heavy metal removal in primary settlers. Coagulation/flocculation and use of low-cost sorbents were identified as the most promising methods for enhancing heavy metal removal during primary settling. Based on the available data on heavy metal speciation and removal during primary settling, sorption technologies may be most effective for enhancing the removal of Cu and Ni, while coagulation may be efficient for Cd, Cr, Cu, Pb, Zn and Hg removal (but not as efficient for Ni removal).